AT A GLANCE
THE CHALLENGE
The PCN was keen to develop more targeted ways of identifying patients at risk of cardiovascular disease (CVD) and bring screening for atrial fibrillation and hyperlipidaemia (high cholesterol) in line with current practices for blood pressure. Heart attacks and strokes had increased over recent years and there was a high prevalence of patients with CVD risk factors who were frequent users of primary care services but take up of NHS Health Checks by this group was low.
More community health services were needed as well as CVD training for staff. There was a variation in processes within primary and secondary care, and between practices. Communication could be improved with other services, practices and patients.
WHAT THEY DID
The project team, comprising PCN staff and the national CLEAR team, sought the views of colleagues across the network’s six practices and other key stakeholders over a six-week period conducting interviews and focus groups. Seven years of PCN data from January 2015 to 31 October 2022 alongside information from regional and national databases was analysed. This showed there were cohorts that were less engaged with services, for example, the 40-49 age group.
CLEAR RECOMMENDATIONS
The main recommendation was the creation of a dedicated CVD team within the existing workforce comprising health coaches, a care coordinator, GP and clinical pharmacist which would be a central point of contact for all CVD patients.
Satellite clinics in community venues across the PCN could be led by the health coaches providing CVD prevention and lifestyle advice. The project team recommended the care coordinator’s role include identifying at risk patients and referring them to the community clinics and the clinical pharmacist carrying out routine medication reviews. There could be point of care cholesterol screening and digital apps used to give patients more flexibility and choice when booking their appointments. A single referral form into the CVD team would improve communication
FORECAST IMPACT
The new model of care would provide a more proactive, preventative approach to CVD resulting in a healthier population. Patients would have better access to services and the level of NHS Health Checks would increase.
Enhanced screening and treatment for patients with high blood pressure (3% optimisation) could prevent five strokes and four heart attacks over three years and better management of patients with high cholesterol (9% optimisation) could prevent three strokes, heart attacks and deaths over five years. It’s forecast that annual PCN productivity savings could total £44,363, from 1,184 reduced appointments and potential additional revenue (Quality and Outcomes Framework and NHS Health Checks) after investment for the new model of care. The prevention of heart attacks and strokes could generate wider system savings of £99,998 over three years. Overall, its estimated the new model of care could lead to a social return on investment (ROI) of £197,924 in 10 years (figures based on £2.30 ROI for every £1 spent on CVD prevention).
